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Revascularization for Advanced Coronary Artery Disease in Type 2 Diabetic Patients: Choosing Wisely Between PCI and Surgery

  • Diabetes and Cardiovascular Disease (SR Wright, Section Editor)
  • Published:
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Abstract

Purpose of Review

Patients with type 2 diabetes mellitus (T2DM) are at an increased risk of systemic atherosclerosis and advanced coronary artery disease (CAD). Herein, we review clinical trials comparing surgical to percutaneous revascularization in the context of the unique pathophysiology in this patient population, and seek to answer the question of optimal strategy of revascularization.

Recent Findings

Early studies showed a signal towards benefit of surgical revascularization over percutaneous revascularization in this group, but there was a paucity of randomized clinical trials (RCT) to directly support this finding. The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM), a large-scale international RCT, was then undertaken and established the benefit of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) in terms of mortality, myocardial infarction and repeat revascularization; CABG was inferior to PCI with regards to stroke. The quality of life and cost effectiveness also demonstrated a long-term benefit for surgery.

Summary

The decision as to choice of mode of revascularization in patients with T2DM and advanced CAD depends upon a multitude of factors, including the coronary anatomy, co-morbidities and the patient’s surgical risk. These factors influence the recommendation of the cardiovascular team, which should result in a balanced presentation of the short and long-term risks and benefits of either mode of revascularization to the patient and his/her family.

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References

Papers of particular interest, published recently, have been highlighted as: •Of importance ••Of major importance

  1. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(1):4–14.

    Article  CAS  PubMed  Google Scholar 

  2. Libby P, Theroux P. Pathophysiology of coronary artery disease. Circulation. 2005;111(25):3481–8.

    Article  PubMed  Google Scholar 

  3. Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes. 1988;37(12):1595–607.

    Article  CAS  PubMed  Google Scholar 

  4. Emond M, Mock MB, Davis KB, Fisher LD, Holmes Jr DR, Chaitman BR, et al. Long-term survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry. Circulation. 1994;90(6):2645–57.

    Article  CAS  PubMed  Google Scholar 

  5. Creager MA, Luscher TF, Cosentino F, Beckman JA. Diabetes and vascular disease: pathophysiology, clinical consequences, and medical therapy: part I. Circulation. 2003;108(12):1527–32.

    Article  PubMed  Google Scholar 

  6. Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339(4):229–34.

    Article  CAS  PubMed  Google Scholar 

  7. Vavuranakis M, Stefanadis C, Toutouzas K, Pitsavos C, Spanos V, Toutouzas P. Impaired compensatory coronary artery enlargement in atherosclerosis contributes to the development of coronary artery stenosis in diabetic patients. An in vivo intravascular ultrasound study. Eur Heart J. 1997;18(7):1090–4.

    Article  CAS  PubMed  Google Scholar 

  8. Silva JA, Escobar A, Collins TJ, Ramee SR, White CJ. Unstable angina. A comparison of angioscopic findings between diabetic and nondiabetic patients. Circulation. 1995;92(7):1731–6.

    Article  CAS  PubMed  Google Scholar 

  9. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med. 1996;335(4):217–25.

    Article  Google Scholar 

  10. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease. Circulation. 1997;96(6):1761–9.

  11. Investigators B. The final 10-year follow-up results from the BARI randomized trial. J Am Coll Cardiol. 2007;49(15):1600–6.

    Article  Google Scholar 

  12. Serruys PW, Unger F, Sousa JE, Jatene A, Bonnier HJ, Schonberger JP, et al. Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med. 2001;344(15):1117–24.

    Article  CAS  PubMed  Google Scholar 

  13. Legrand VM, Serruys PW, Unger F, van Hout BA, Vrolix MC, Fransen GM, et al. Three-year outcome after coronary stenting versus bypass surgery for the treatment of multivessel disease. Circulation. 2004;109(9):1114–20.

    Article  PubMed  Google Scholar 

  14. Lawrie GM, Morris Jr GC, Glaeser DH. Influence of diabetes mellitus on the results of coronary bypass surgery. Follow-up of 212 diabetic patients ten to 15 years after surgery. JAMA. 1986;256(21):2967–71.

    Article  CAS  PubMed  Google Scholar 

  15. Mehran R, Dangas GD, Kobayashi Y, Lansky AJ, Mintz GS, Aymong ED, et al. Short- and long-term results after multivessel stenting in diabetic patients. J Am Coll Cardiol. 2004;43(8):1348–54.

    Article  PubMed  Google Scholar 

  16. Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Brooks MM, et al. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet. 2009;373(9670):1190–7.

    Article  PubMed  Google Scholar 

  17. Moses JW, Leon MB, Popma JJ, Fitzgerald PJ, Holmes DR, O'Shaughnessy C, et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med. 2003;349(14):1315–23.

    Article  CAS  PubMed  Google Scholar 

  18. Group BDS, Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, et al. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360(24):2503–15.

    Article  Google Scholar 

  19. Kim LJ, King 3rd SB, Kent K, Brooks MM, Kip KE, Abbott JD, et al. Factors related to the selection of surgical versus percutaneous revascularization in diabetic patients with multivessel coronary artery disease in the BARI 2D (bypass angioplasty revascularization investigation in type 2 diabetes) trial. JACC Cardiovasc Interv. 2009;2(5):384–92.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Feit F, Brooks MM, Sopko G, Keller NM, Rosen A, Krone R, et al. Long-term clinical outcome in the bypass angioplasty revascularization investigation registry: comparison with the randomized trial. BARI Investigators Circulation. 2000;101(24):2795–802.

    CAS  PubMed  Google Scholar 

  21. Kamalesh M, Sharp TG, Tang XC, Shunk K, Ward HB, Walsh J, et al. Percutaneous coronary intervention versus coronary bypass surgery in United States veterans with diabetes. J Am Coll Cardiol. 2013;61(8):808–16.

    Article  PubMed  Google Scholar 

  22. Kapur A, Hall RJ, Malik IS, Qureshi AC, Butts J, de Belder M, et al. Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (coronary artery revascularization in diabetes) trial. J Am Coll Cardiol. 2010;55(5):432–40.

    Article  PubMed  Google Scholar 

  23. •• Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961–72. This is a landmark large-scale randomized study (SYNTAX) that compares percutaneous coronary intervention to bypass surgery.

  24. • Kappetein AP, Head SJ, Morice MC, Banning AP, Serruys PW, Mohr FW, et al. Treatment of complex coronary artery disease in patients with diabetes: 5-year results comparing outcomes of bypass surgery and percutaneous coronary intervention in the SYNTAX trial. European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery. 2013;43(5):1006–13. This is a very valuable 5-year follow-up of the landmark study SYNTAX in patients with diabetes.

  25. Farkouh ME, Dangas G, Leon MB, Smith C, Nesto R, Buse JB, et al. Design of the Future REvascularization evaluation in patients with diabetes mellitus: optimal management of multivessel disease (FREEDOM) trial. Am Heart J. 2008;155(2):215–23.

    Article  PubMed  Google Scholar 

  26. Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503–16.

    Article  CAS  PubMed  Google Scholar 

  27. Bansilal S, Farkouh ME, Hueb W, Ogdie M, Dangas G, Lansky AJ, et al. The Future REvascularization Evaluation in patients with diabetes mellitus: optimal management of multivessel disease (FREEDOM) trial: clinical and angiographic profile at study entry. Am Heart J. 2012;164(4):591–9.

    Article  PubMed  PubMed Central  Google Scholar 

  28. •• Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367(25):2375–84. This is the first large-scale study that randomized patients with diabetes and multivessel disease to different revascularization strategies.

  29. Bangalore S, Toklu B, Feit F. Outcomes with coronary artery bypass graft surgery versus percutaneous coronary intervention for patients with diabetes mellitus: can newer generation drug-eluting stents bridge the gap? Circulation cardiovascular interventions. 2014.

    Google Scholar 

  30. Verma S, Farkouh ME, Yanagawa B, Fitchett DH, Ahsan MR, Ruel M, et al. Comparison of coronary artery bypass surgery and percutaneous coronary intervention in patients with diabetes: a meta-analysis of randomised controlled trials. The lancet Diabetes & endocrinology. 2013;1(4):317–28.

    Article  Google Scholar 

  31. Dangas GD, Farkouh ME, Sleeper LA, Yang M, Schoos MM, Macaya C, et al. Long-term outcome of PCI versus CABG in insulin and non-insulin-treated diabetic patients: results from the FREEDOM trial. J Am Coll Cardiol. 2014;64(12):1189–97.

    Article  CAS  PubMed  Google Scholar 

  32. Eckel RH, Wassef M, Chait A, Sobel B, Barrett E, King G, et al. Prevention Conference VI: Diabetes and Cardiovascular Disease: Writing Group II: pathogenesis of atherosclerosis in diabetes. Circulation. 2002;105(18):e138–43.

    Article  PubMed  Google Scholar 

  33. Tector AJ, Schmahl TM, Janson B, Kallies JR, Johnson G. The internal mammary artery graft. Its longevity after coronary bypass. JAMA. 1981;246(19):2181–3.

    Article  CAS  PubMed  Google Scholar 

  34. Detre KM, Guo P, Holubkov R, Califf RM, Sopko G, Bach R, et al. Coronary revascularization in diabetic patients: a comparison of the randomized and observational components of the Bypass Angioplasty Revascularization Investigation (BARI). Circulation. 1999;99(5):633–40.

    Article  CAS  PubMed  Google Scholar 

  35. Mancini GB, Farkouh ME, Brooks MM, Chaitman BR, Boden WE, Vlachos H, et al. Medical treatment and revascularization options in patients with type 2 diabetes and coronary disease. J Am Coll Cardiol. 2016;68(10):985–95.

    Article  PubMed  Google Scholar 

  36. Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the collaborative atorvastatin diabetes study (CARDS): multicentre randomised placebo-controlled trial. Lancet. 2004;364(9435):685–96.

    Article  CAS  PubMed  Google Scholar 

  37. American DA. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14–80.

    Article  Google Scholar 

  38. Patel A, Group AC, MacMahon S, Chalmers J, Neal B, Woodward M, et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet. 2007;370(9590):829–40.

    Article  CAS  PubMed  Google Scholar 

  39. Xie X, Atkins E, Lv J, Bennett A, Neal B, Ninomiya T, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387(10017):435–43.

    Article  PubMed  Google Scholar 

  40. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359(15):1577–89.

    Article  CAS  PubMed  Google Scholar 

  41. Group AS, Cushman WC, Evans GW, Byington RP, Goff Jr DC, Grimm Jr RH, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1575–85.

    Article  Google Scholar 

  42. Standards of Medical Care in Diabetes-2016. Summary of revisions. Diabetes Care. 2016;(39 Suppl 1):S4–5.

  43. Corpus RA, George PB, House JA, Dixon SR, Ajluni SC, Devlin WH, et al. Optimal glycemic control is associated with a lower rate of target vessel revascularization in treated type II diabetic patients undergoing elective percutaneous coronary intervention. J Am Coll Cardiol. 2004;43(1):8–14.

    Article  PubMed  Google Scholar 

  44. Mauri L, Kereiakes DJ, Yeh RW, Driscoll-Shempp P, Cutlip DE, Steg PG, et al. Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med. 2014;371(23):2155–66.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Gargiulo G, Windecker S, da Costa BR, Feres F, Hong MK, Gilard M, et al. Short term versus long term dual antiplatelet therapy after implantation of drug eluting stent in patients with or without diabetes: systematic review and meta-analysis of individual participant data from randomised trials. BMJ. 2016;355:i5483.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Abdallah MS, Wang K, Magnuson EA, Spertus JA, Farkouh ME, Fuster V, et al. Quality of life after PCI vs CABG among patients with diabetes and multivessel coronary artery disease: a randomized clinical trial. JAMA. 2013;310(15):1581–90.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Kozlov KL, Bogachev AA. Coronary revascularization in the elderly with stable angina. J Geriatr Cardiol. 2015;12(5):555–68.

    PubMed  PubMed Central  Google Scholar 

  48. Magnuson EA, Farkouh ME, Fuster V, Wang K, Vilain K, Li H, et al. Cost-effectiveness of percutaneous coronary intervention with drug eluting stents versus bypass surgery for patients with diabetes mellitus and multivessel coronary artery disease: results from the FREEDOM trial. Circulation. 2013;127(7):820–31.

    Article  PubMed  Google Scholar 

  49. Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2014;130(19):1749–67.

    Article  PubMed  Google Scholar 

  50. Gossl M, Faxon DP, Bell MR, Holmes DR, Gersh BJ. Complete versus incomplete revascularization with coronary artery bypass graft or percutaneous intervention in stable coronary artery disease. Circulation Cardiovascular interventions. 2012;5(4):597–604.

    Article  PubMed  Google Scholar 

  51. Sarno G, Garg S, Onuma Y, Gutierrez-Chico JL, van den Brand MJ, Rensing BJ, et al. Impact of completeness of revascularization on the five-year outcome in percutaneous coronary intervention and coronary artery bypass graft patients (from the ARTS-II study). Am J Cardiol. 2010;106(10):1369–75.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Medicine, Division of Cardiology, New York University Langone Medical Center, New York, NY, 10016, USA

    Louai Razzouk & Frederick Feit

  2. Peter Munk Cardiac Centre, Toronto, Ontario, Canada

    Michael E. Farkouh

  3. Heart and Stroke Richard Lewar Centre of Excellence in CV Research, University of Toronto, Toronto, Ontario, Canada

    Michael E. Farkouh

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  1. Louai Razzouk
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  2. Frederick Feit
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  3. Michael E. Farkouh
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Correspondence to Louai Razzouk.

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Louai Razzouk declares that he has no conflict of interest.

Frederick Feit declares to be a shareholder of Johnson & Johnson, Boston Scientific, and Medtronic PLC.

Michael E. Farkouh declares that he has no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Diabetes and Cardiovascular Disease

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Razzouk, L., Feit, F. & Farkouh, M.E. Revascularization for Advanced Coronary Artery Disease in Type 2 Diabetic Patients: Choosing Wisely Between PCI and Surgery. Curr Cardiol Rep 19, 37 (2017). https://doi.org/10.1007/s11886-017-0849-7

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